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i <br /> { -— - A0'off <br /> WELL/PUMP PERMIT <br /> SAN 7OAoum COUNTY ENVIRONMENTAL rRDEPARTmM 304 E WEBER AVE 3 -r STOCKTON CA 95202-(209)468-3420 <br /> j <br /> NON-REFUNDABLE PERMIT CALL. 209 953-7697 FOR INSPECTIONS - EXPIRES 1 YEAR FROM DATE ISSUED <br /> ��/_ --- <br /> r <br /> Jog AnnktEss C 7 r- r 0 fa +�V/'�� �//� — — Ct Vr4z({tr��- 7�►rt 9 S 3 36 <br /> CRoss STREET F+rj►tC APN i91Zl0©•.V't-PARCEL SIZE !"-%3,.AND USE APPLICATION# <br /> OWNER NAME e t-(t'.(>"'1'o-�-'4'�t•t-'7 LAY,,. �'�!/�.•�T AL- PHONE <br /> i OWNERADDRE53 / } �1 LEA <br /> 'jam I f CrtYISTAT..IP ' ` <br /> CONrpAcrOR GA Jcl E�f 1 k 1' A{nen I��- -.00 .:n C— `PHONE/2��J z� <br /> CONPRACTORADDRESS ..-LOO <br /> iFr ++ 1 �r �• -' CITYISrATFIZIP J�L1GpfOr. C,4- 95z�6 <br /> SUBCONTRACTOR y r /�+tcv l i .nJ i /yNONNB RZ 5 313 58610 <br /> SUBCONTRACt•OR ADDRESS ' `O�/G. I`C�` CITY/ST/AnTEMPP /t .. J•tG� ar q(fg:a.. <br /> _)51:C-57LICENSE �-57 EIC-61_-'- O D-6" 1304)tifer+�'�^ r aj- NUMBEER AZT VO E%PIRATkON DATE <br /> GEOGRAPHICAL INFORMATION:'CooTdlnates ,%•• 'l J?�O Y .Z J p Township Range , Section <br /> INrENDEII USE ❑Domestic/Private i.• ala Irrigation/Agricultural ,O.Industrial 0 Water Quality Monitoring` ..: 'Soil Sampling/Charaeterization <br /> O Public Water System , <br /> , <br /> Ifdiiy—tfmm Owner: ConInct Nannea Phone Nuniber <br /> fTYPE OF WORK O New Well [I Replacement Well O Well Altesation/Modificalion O Other , <br /> 4} N of borings P'ofbonnp <br /> 0 Monitoring Well{s) .N ofwells O Soil.Boring(s) .XGeutechnical <br /> O Out-Of-Service Well ,t0 Out-0f-Service W_ell Renewal ❑Cross-Connection Repair <br /> 0 New Pump O Pump Replacement ,..O Pump Repair <br /> WELLCONSTRUCTION <br /> Drilling Method O Mild Rotary -O Air Rotary ❑Auger "`"O Cable Tool Etksh Point ❑Other <br /> Proposed Well Dcpth ft Excavation in:11 iameter , 0 Open Bottom O Gravel Pack 1 Gravel_Size in diameter Vr• <br /> 0 Conductor Casing in diameter I Conductor Casing Depth it f'h <br /> I <br /> well Casing Diameter_in ThicknesslGauge)ASTM Sched . 0 Steel 0 Plastic ❑Stainless Steel 0 Other, <br /> Grout Seal Depth 1-0-5e, ft )"eat Cement(914 It,bag 13-10 gal xrrter) O Sand Cement sack mix 17 gel water <br /> 0 Bentonite(20%solids) O Manufacturer Spec%solids % Name 0 Specs on File O Specs Submitted <br /> Grout Placement Method 26.Pumped XFrce Fall 0 Other 0 Retardant!Accelerator(name) <br /> j PEDESFAL Installed By O Driller O Pump Contractor 0 Other <br /> 0 Concrete Pedestal Dimensions:Width ••ft Length It Thick in 0 Christy Bax O Stove Plpe - <br />' PUMp 0 Submersible O Turbine ❑Oihcr .HP - 'Pump Set ft Standing Water Level ft O <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN' � <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED,LICENSE 1S <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE HOARD AND THAT I AM IN COMPLIANCE WITH-ALL <br /> WORKERS COMPENSATION LAWS d <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIREDFOR INSPECTIONS <br /> t p f // <br /> SIGNED .7./(�' TITLE !7'SS'A C+ ��'., DATE• 1/2[!!n <br /> MID iia <br /> PPW <br /> Rr <br /> � �aYali r� i"oR <br /> e <br /> DO <br /> -R!04._ .. rat g+�'.,M' <br /> . SEP 2 OZ <br /> 20 <br /> sts► taa tut�rlTn► <br /> fit" <br /> -,.D E PAR T M.E NT U E„O!N L-7Y - t,' <br /> E Application Accepted By. Date ALL 0 / Area Employer ID# 7�Z <br /> > Grout Inspection By` -'Date�9�f a* ❑t SPECIALWCII.Perm)t' g, <br /> Pump inspection By .Date.-' . - '-;” t'.. 40 -WAIVER Received- <br /> Constructed Well Depth ft .• Jr. . <br /> i, COMMENTS 2 <br /> A <br /> PE SC Received heciall 1 Amount Permit/ _ <br /> Codes Info R Remllted ©nee Service Re uest# lnvoicell Well IDN <br /> 'f372 !eS O u6 U 8'61' 5goQ 5 2 I uD <br /> EHD43-02-006 - - - - WELL PUMP PERMFr <br /> tavlao5 <br />